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Influenza in patients with chronic inflammatory disorders – FAQ 23/09/2009
Are patients with chronic inflammatory disorders at increased risk for influenza and
influenza complications?

Chronic inflammatory disorders occur in different fields of medicine, and include chronic arthritis, Crohn’s disease, psoriasis and others. In general, most of these disorders do not cause immune depression by themselves (although there are exceptions). Rather, some of the therapies prescribed to such patients, may indeed suppress in some way the normal immune surveillance, potentially leading to an increased susceptibility for influenza or an increased risk for complications in case of an influenza infection (eg bacterial surinfections following the flu). Drugs frequently used in patients with chronic inflammatory disorders, which do not suppress normal immunity are: non-steroidal anti-inflammatory drugs (aspirin, diclofenac, piroxicam, ibuprofen, and others), anti-malarials, sulfasalazine, mesalasine, drugs for external (cutaneous) use. Drugs which are considered to be associated with an immunosuppressive risk include: methotrexate, azathioprine, leflunomide, cyclosporine, cyclophosphamide, and the so-called biological drugs (anti-TNF therapy, rituximab, tocilizumab, abatacept, ustekinumab). Chronic use of corticosteroids (longer than 2 weeks) may suppress normal immunity, depending upon dose and duration of this therapy. The list of drugs cited here is not limitative; specific situations should be discussed with the treating physician. Can flu-symptoms be masked by immunosuppressive drugs?
Yes. Patients taking corticosteroids or other immunosuppressive drugs may present less marked flu-signs (less fever), thus masking partially the infection. Therefore, both patients and physicians should be more alert in case of a general malaise, even in the absence of high fever, especially if there have been contacts with flu cases. Are there any specific measures to be taken for patients with a chronic inflammatory
disorder under immunosuppressive therapy in relation with the pandemic flu?

Patients (both adults and children) with a chronic inflammatory disorder under immunosuppressive therapy should contact their general practitioner as soon as flu-symptoms appear (acute onset of fever, coughing). If the general physician suspects flu, antiviral therapy will be provided. With the exception of corticosteroids, the intake or administration of other immunosuppressives (classical immunosuppressives and biological) should be postponed, until disappearance of all flu-symptoms. Abrupt interruption of chronic corticotherapy may be hazardous, and should be avoided. There is no need for a preventive interruption of therapy in the absence of infectious symptoms. Given the particular immune status of patients with a chronic inflammatory disorder under immune therapy, these patients should seek – in general - optimal vaccination protection, not only against the flu, but also against other preventable infectious disorders like pneumococci or hepatitis. Such measures are not limited in time to the current era of flu pandemy, but should in general be taken into account.


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